Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Murder, vitriol, and hidden costs: inside the health insurance industry’s biggest battles

Lynne Moronski, PhD, MPA, RN
Policy
February 6, 2025
Share
Tweet
Share

With the murder of the UnitedHealthcare CEO, many have expressed vitriol towards the insurance industry.

Having worked in non-profit health care all my life, I decided in 2018 to switch to the “dark side,” or the insurance industry, out of curiosity. What is it that they do, and how are they doing it? I thought knowing would make me a better health care worker when I returned.

As a registered nurse case manager, I was in the room where it happened: approvals, denials, and decisions. These were rational and straightforward. Clinical guidelines were followed, and medical reviews were completed by MDs. I worked for a Blue Cross Blue Shield plan. Nothing was ever done out of malice or profit. It was an honorable process.

I learned that employers and other entities choose benefit options like an à la carte buffet. This means that what the employer selects must be carefully weighed against what the patient wants. A member was irate that we wouldn’t pay for a service dog. It’s a wonderful idea, but I couldn’t approve it because the employer had not chosen that as a covered benefit.

Nevertheless, I came to realize that the system is full of hidden traps and unexpected costs, and it’s hard for people to differentiate between the insurer and the system’s broken rules. We need to rescue people from the quicksand of surprise bills and many other things, but that’s going to take a lot of work from regulators, legislators, and insurers.

Not only am I an insider, but I am a heavy user of health insurance. An out-of-network provider of mine raised his rates 83 percent to $550 per visit. I submitted the bill, insurance balked, demanded medical records, and took up to six months to reimburse me. I decided to switch to an in-network provider rather than be hassled further. That said, I will miss my doctor of 10 years. No one is looking out for the consumer.

The huge bill from an out-of-network provider is a great example of the traps that lie in wait for patients. There are many others, ranging from shocking ambulance bills to the $1,600 that traditional Medicare patients must pay for a hospital stay. It feels like an organized crime shakedown when you’re on the receiving end.

Medical problems are cited by two-thirds of bankruptcy petitioners as a major factor in their financial collapse. Although filing for bankruptcy has long been prompted by the high cost of care, research indicates that the Affordable Care Act has not fixed the problem. Most consumers are unaware that their health insurance can be insufficient to protect them.

Helen Hunt, in the 1997 movie As Good As It Gets, rages against her HMO when it won’t cover her asthmatic son’s treatment. Her magnificent meltdown made audiences cheer in the theater. But while the scene had elements of truth to it, it was way overdone. Many insurers run excellent preventive programs for patients with asthma. They have a big incentive to keep members well and out of the hospital.

The reality is our system can’t afford all the care that people want. The insurer is the gatekeeper whose task is to say no. It’s the reality check that’s sure to get a lot of flak.

I suspect that AI systems have contributed to the backlash against insurers. Call any business, and there is an automated menu to wade through. Insurers and large pharmacies make it particularly hard to reach a human being. I started refilling my daughter’s prescription at 8:30 a.m. and didn’t complete it until two hours later. When the pharmacy started refilling the prescription, the copay card had a problem. Eventually, it was fixed, and the prescription refilled. But this took eight phone calls. Even I felt my tone rising.

What consumers need is a sherpa to guide them through the Himalayas of health care. Some employers buy these advisory services for their staff, so ask about it. Lacking that, you must be your own best advocate. Rather than blaming the insurance industry, we need to be proactive in working with them. Keep your receipts. Take notes of every interaction. Always be polite as well as professional and concise in your communications. Tell them what you would like them to do.

And escalate the problem to the next level if needed. If all efforts fail, call your local senator or reach out to the state insurance commissioner because they regulate insurers. State Health Insurance Assistance Programs (SHIP) can also be helpful for complaints.

ADVERTISEMENT

Remember, the people who answer the phone are insured like you are and may even have the same benefits. They’re the bouncers we’ve created to keep the billing process honest.

Lynne Moronski is a post-doctoral research fellow.

Prev

The best job boards for finding unconventional medical jobs, side gigs, and moonlighting opportunities

February 6, 2025 Kevin 0
…
Next

Marijuana's hidden threat to fertility and family planning [PODCAST]

February 6, 2025 Kevin 0
…

Tagged as: Public Health & Policy

Post navigation

< Previous Post
The best job boards for finding unconventional medical jobs, side gigs, and moonlighting opportunities
Next Post >
Marijuana's hidden threat to fertility and family planning [PODCAST]

ADVERTISEMENT

More by Lynne Moronski, PhD, MPA, RN

  • From ER overload to genetic breakthrough: How allergies transformed my life and career

    Lynne Moronski, PhD, MPA, RN

Related Posts

  • Why the health care industry must prioritize health equity

    George T. Mathew, MD, MBA
  • High deductible health insurance is bankrupting Americans

    Ben Aiken, MD
  • COVID-19 shows why we need health insurance

    Jingyi Liu, MD
  • To address youth mental health, we must address insurance barriers

    Alex Stavros, MBA
  • Make your health insurance broker a translator, not a shopper

    Rushi Nagalla
  • Clinicians unite for health care reform

    Leslie Gregory, PA-C

More in Policy

  • Why health care leaders fail at execution—and how to fix it

    Dave Cummings, RN
  • Healing the doctor-patient relationship by attacking administrative inefficiencies

    Allen Fredrickson
  • The hidden health risks in the One Big Beautiful Bill Act

    Trevor Lyford, MPH
  • The CDC’s restructuring: Where is the voice of health care in the room?

    Tarek Khrisat, MD
  • Choosing between care and country: a dual citizen’s Independence Day reflection

    Kathleen Muldoon, PhD
  • How fragmented records and poor tracking degrade patient outcomes

    Michael R. McGuire
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • 5 blind spots that stall physician wealth

      Johnny Medina, MSc | Finance
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Recent Posts

    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician
    • How veteran health care is being transformed by tech and teamwork

      Deborah Lafer Scher | Conditions
    • Why judgment is hurting doctors—and how mindfulness can heal

      Jessie Mahoney, MD | Physician
    • Why medical schools must ditch lectures and embrace active learning

      Arlen Meyers, MD, MBA | Education
    • Why helping people means more than getting an MD

      Vaishali Jha | Education
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • 5 blind spots that stall physician wealth

      Johnny Medina, MSc | Finance
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Recent Posts

    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician
    • How veteran health care is being transformed by tech and teamwork

      Deborah Lafer Scher | Conditions
    • Why judgment is hurting doctors—and how mindfulness can heal

      Jessie Mahoney, MD | Physician
    • Why medical schools must ditch lectures and embrace active learning

      Arlen Meyers, MD, MBA | Education
    • Why helping people means more than getting an MD

      Vaishali Jha | Education
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...